<%-- 
    Document   : jspRegistrarHistorial
    Created on : 20/09/2011, 12:45:04 AM
    Author     : yohanna
--%>

<%@page contentType="text/html" pageEncoding="UTF-8"%>
<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
   "http://www.w3.org/TR/html4/loose.dtd">

<html>
    <head>
        <meta http-equiv="Content-Type" content="text/html; charset=UTF-8">
        <title>JSP Page</title>
    </head>
    <body>
        <form class="jotform-form" action="http://submit.jotform.com/submit.php" method="post" name="form_12614529325" id="12614529325" accept-charset="utf-8">
  <input type="hidden" name="formID" value="12614529325" />
  <div class="form-all">
    <h2 id="header_1" class="style1">Seguimientos
          </h2>
    <ul class="form-section">
      <li class="form-line" id="id_2">
        <label class="form-label-left" id="label_2" for="input_2"> Código:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </label>
          <input type="text" class="form-textbox" id="input_2" name="q2_codigo" size="20" /><div id="cid_2" class="form-input">
          &nbsp;</div>
      </li>
      <li class="form-line" id="id_5">
        <label class="form-label-left" id="label_5" for="input_5"> Altura (cms): </label>
          <input type="text" class="form-textbox" id="input_5" name="q5_altura" size="20" /><div id="cid_5" class="form-input">
          &nbsp;</div>
      </li>
      <li class="form-line" id="id_3">
        <label class="form-label-left" id="label_3" for="input_3"> Peso (gr):&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </label>
          <input type="text" class="form-textbox" id="input_3" name="q3_pesogr" size="20" /><div id="cid_3" class="form-input">
          &nbsp;</div>
      </li>
      <li class="form-line" id="id_6">
        <label class="form-label-left" id="label_6" for="input_6"> Fecha: </label>
		<div id="cid_6" class="form-input"><span class="form-sub-label-container"><select class="form-dropdown" name="q6_fecha[month]" id="input_6_month">
              <option>  </option>
              <option value="Enero"> Enero </option>
              <option value="Febrero"> Febrero </option>
              <option value="Marzo"> Marzo </option>
              <option value="Abril"> Abril </option>
              <option value="Mayo"> Mayo </option>
              <option value="Junio"> Junio </option>
              <option value="Julio"> Julio </option>
              <option value="Agosto"> Agosto </option>
              <option value="Septiembre"> Septiembre </option>
              <option value="Octubre"> Octubre </option>
              <option value="De noviembre"> De noviembre </option>
              <option value="Diciembre"> Diciembre </option>
            </select>
            <label class="form-sub-label" for="input_6_month" id="sublabel_month"> Mes </label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q6_fecha[day]" id="input_6_day">
              <option>  </option>
              <option value="31"> 31 </option>
              <option value="30"> 30 </option>
              <option value="29"> 29 </option>
              <option value="28"> 28 </option>
              <option value="27"> 27 </option>
              <option value="26"> 26 </option>
              <option value="25"> 25 </option>
              <option value="24"> 24 </option>
              <option value="23"> 23 </option>
              <option value="22"> 22 </option>
              <option value="21"> 21 </option>
              <option value="20"> 20 </option>
              <option value="19"> 19 </option>
              <option value="18"> 18 </option>
              <option value="17"> 17 </option>
              <option value="16"> 16 </option>
              <option value="15"> 15 </option>
              <option value="14"> 14 </option>
              <option value="13"> 13 </option>
              <option value="12"> 12 </option>
              <option value="11"> 11 </option>
              <option value="10"> 10 </option>
              <option value="9"> 9 </option>
              <option value="8"> 8 </option>
              <option value="7"> 7 </option>
              <option value="6"> 6 </option>
              <option value="5"> 5 </option>
              <option value="4"> 4 </option>
              <option value="3"> 3 </option>
              <option value="2"> 2 </option>
              <option value="1"> 1 </option>
            </select>
            <label class="form-sub-label" for="input_6_day" id="sublabel_day"> Día </label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q6_fecha[year]" id="input_6_year">
              <option>  </option>
              <option value="2015"> 2015 </option>
              <option value="2014"> 2014 </option>
              <option value="2013"> 2013 </option>
              <option value="2012"> 2012 </option>
              <option value="2011"> 2011 </option>
              <option value="2010"> 2010 </option>
              <option value="2009"> 2009 </option>
              <option value="2008"> 2008 </option>
              <option value="2007"> 2007 </option>
              <option value="2006"> 2006 </option>
              <option value="2005"> 2005 </option>
              <option value="2004"> 2004 </option>
              <option value="2003"> 2003 </option>
              <option value="2002"> 2002 </option>
              <option value="2001"> 2001 </option>
              <option value="2000"> 2000 </option>
              <option value="1999"> 1999 </option>
              <option value="1998"> 1998 </option>
              <option value="1997"> 1997 </option>
              <option value="1996"> 1996 </option>
              <option value="1995"> 1995 </option>
              <option value="1994"> 1994 </option>
              <option value="1993"> 1993 </option>
              <option value="1992"> 1992 </option>
              <option value="1991"> 1991 </option>
              <option value="1990"> 1990 </option>
              <option value="1989"> 1989 </option>
              <option value="1988"> 1988 </option>
              <option value="1987"> 1987 </option>
              <option value="1986"> 1986 </option>
              <option value="1985"> 1985 </option>
              <option value="1984"> 1984 </option>
              <option value="1983"> 1983 </option>
              <option value="1982"> 1982 </option>
              <option value="1981"> 1981 </option>
              <option value="1980"> 1980 </option>
              <option value="1979"> 1979 </option>
              <option value="1978"> 1978 </option>
              <option value="1977"> 1977 </option>
              <option value="1976"> 1976 </option>
              <option value="1975"> 1975 </option>
              <option value="1974"> 1974 </option>
              <option value="1973"> 1973 </option>
              <option value="1972"> 1972 </option>
              <option value="1971"> 1971 </option>
              <option value="1970"> 1970 </option>
              <option value="1969"> 1969 </option>
              <option value="1968"> 1968 </option>
              <option value="1967"> 1967 </option>
              <option value="1966"> 1966 </option>
              <option value="1965"> 1965 </option>
              <option value="1964"> 1964 </option>
              <option value="1963"> 1963 </option>
              <option value="1962"> 1962 </option>
              <option value="1961"> 1961 </option>
              <option value="1960"> 1960 </option>
              <option value="1959"> 1959 </option>
              <option value="1958"> 1958 </option>
              <option value="1957"> 1957 </option>
              <option value="1956"> 1956 </option>
              <option value="1955"> 1955 </option>
              <option value="1954"> 1954 </option>
              <option value="1953"> 1953 </option>
              <option value="1952"> 1952 </option>
              <option value="1951"> 1951 </option>
              <option value="1950"> 1950 </option>
              <option value="1949"> 1949 </option>
              <option value="1948"> 1948 </option>
              <option value="1947"> 1947 </option>
              <option value="1946"> 1946 </option>
              <option value="1945"> 1945 </option>
              <option value="1944"> 1944 </option>
              <option value="1943"> 1943 </option>
              <option value="1942"> 1942 </option>
              <option value="1941"> 1941 </option>
              <option value="1940"> 1940 </option>
              <option value="1939"> 1939 </option>
              <option value="1938"> 1938 </option>
              <option value="1937"> 1937 </option>
              <option value="1936"> 1936 </option>
              <option value="1935"> 1935 </option>
              <option value="1934"> 1934 </option>
              <option value="1933"> 1933 </option>
              <option value="1932"> 1932 </option>
              <option value="1931"> 1931 </option>
              <option value="1930"> 1930 </option>
              <option value="1929"> 1929 </option>
              <option value="1928"> 1928 </option>
              <option value="1927"> 1927 </option>
              <option value="1926"> 1926 </option>
              <option value="1925"> 1925 </option>
              <option value="1924"> 1924 </option>
              <option value="1923"> 1923 </option>
              <option value="1922"> 1922 </option>
              <option value="1921"> 1921 </option>
              <option value="1920"> 1920 </option>
            </select>
            <label class="form-sub-label" for="input_6_year" id="sublabel_year"> Año </label></span>
        </div>
      </li>
      <li style="display:none">Should be Empty:
        <input type="text" name="website" value="" /> </li>
    </ul>
  </div>
  <input type="hidden" id="simple_spc" name="simple_spc" value="12614529325" />
  <script type="text/javascript">
  document.getElementById("si" + "mple" + "_spc").value = "12614529325-12614529325";
  </script>
   <ul class="form-section">
      <li class="form-line" id="id_7">
        <label class="form-label-left" id="label_7" for="input_7"> Observaciones: </label>
        <div id="cid_7" class="style1">
          <textarea id="input_7" class="form-textarea" name="q7_obsercaciones" cols="40" rows="6"></textarea><br />
			<br />
			<br />
			<br />
			<br />
            <button id="input_8" type="submit" class="form-submit-button">
              Aceptar
            </button>
          &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
			<input name="Submit1" type="submit" value="Regresar" /></div>
      </li>
    </ul>

</form><script type="text/javascript"/>


</body>
</html>
